How the DOJ Is Tackling Fraud in the ACA Marketplace
At the Medicarians Conference, Ricardo Carcas, assistant special agent in charge of the Office of Investigations, discussed cases of fraud in the ACA and how the DOJ is combatting it.
Healthcare’s Paper Check Problem
By adopting a modern digital payment solution, payers can streamline operations, improve provider relationships and reduce fraud exposure. Most importantly, they gain a flexible, scalable foundation built to meet today’s demands and tomorrow’s challenges.
Beyond Analytics: How Sellers Dorsey is Hard-Coding Value into Medicaid Policy [Video]
How to turn analytics into actual policy outcomes.
Kaiser Permanente to Pay $556M to Settle Medicare Advantage Fraud Allegations
Five Kaiser Permanente affiliates agreed to pay $556 million to settle allegations from the Department of Justice that they improperly inflated Medicare Advantage payments through inaccurate diagnosis coding. The case is one of the largest risk-adjustment settlements to date — and it signals continued federal scrutiny of the program.
Ex-Cano Health CEO Faces $72M Fraud Claims
Marlow Hernandez, the founder and former CEO of Cano Health, was set to face a trial over allegations that he fraudulently enriched himself and his family while managing the senior-focused primary care company. Cano filed for bankruptcy last year — an event many industry experts attributed to Hernandez’ poor governance.
Dr. Oz Says the Medicaid Program is Complicit in ‘Legalized Money Laundering’
CMS Administrator Dr. Mehmet Oz said that Medicaid’s rapid spending growth is unsustainable and criticized state financing tactics that let providers and governments “game” the system for extra federal funds. He said CMS is shifting its fraud strategy to follow the flow of money rather than just individual offenders in an effort to ensure health dollars are used for legitimate care.
Credit Monitoring Won’t Save You: The True Fallout of the Change Healthcare Hack is Just Beginning
The attack has given detailed dossiers on millions of lives to criminals, employers, enemies and anyone with the means and motivation to exploit them. This isn't just another data breach, it's a healthcare catastrophe — and it's being inexplicably downplayed.
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Inside an Automated Healthcare Practice: Redesigning Care Around People, Not Paperwork
By reducing administrative burden and redesigning workflows around human needs, it creates space for what matters most: connection between clinicians and patients.
Former Outcome Health Execs Found Guilty of 47 Counts of Fraud
A federal jury found three former Outcome Health executives guilty of 47 counts of fraud. The convictions come after a 10-week trial that investigated the former leaders’ role in a billion-dollar scheme in which the company lied to its customers about how many physicians' offices their advertisements would appear in.
What do GCs need to know to advise clients to avoid telehealth fraud?
What's interesting in this special fraud alert and what was somewhat new is the dual emphasis on marketing and clinical decision making.
DOJ charges dozens for $1.2B in telemedicine fraud scheme
The charges involve some of the first cases in the country involving fraudulent cardiovascular genetic testing, a “burgeoning scheme,” according to a news release from the DOJ.
DOJ accuses Kaiser Permanente of Medicare Advantage fraud in new complaint
The California-based health system and insurer has bilked CMS out of "hundreds of millions of dollars" by submitting claims that were altered to make patients appear sicker than they were, a new complaint filed by the DOJ alleges. Kaiser denied these allegations saying it is confident in its compliance with Medicare Advantage program requirements.
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Survey on the Healthcare Financial Landscape Offers a Roadmap for Stakeholders
Zelis highlights how employers, payers, and consumers are integrating digital tools to manage healthcare costs.
Racism, sexism and now fraud: Lawsuits pile up at New Jersey ‘AI’ firm
A previous investigation by MedCity News found that ElectrifAi was touting an improperly-developed algorithm during the earliest phase of the Covid-19 pandemic, with both the company and CEO defendants in an employment discrimination lawsuit. A year later, lawsuits are piling up as more former employees complain that the company and CEO lied about its AI capabilities and business.
Sutter Health to pay $90M to resolve False Claims allegations
The California-based health system will pay a hefty price to resolve allegations that it knowingly submitted inflated diagnosis codes for certain Medicare Advantage beneficiaries to receive higher payments. Sutter Health does not admit any liability in the matter.
Justice Department joins False Claims lawsuits against Kaiser Permanente
The government has intervened in complaints alleging Kaiser Permanente entities defrauded Medicare out of "tens of millions of dollars" by knowingly submitting false diagnoses for Medicare Advantage beneficiaries. Kaiser denies the allegations, saying it is in compliance with program requirements.
SEC charges uBiome co-founders with $60M securities fraud
The agency charged the co-founders of the failed fecal microbiome startup with defrauding investors. The SEC is seeking a court order that would bar uBiome’s co-founders from serving as officers or directors, and require them to give up any ill-gotten gains.
DOJ cracks down on telehealth kickbacks in $6B fraud investigation
The investigation resulted in charges against more than 345 defendants for more than $6 billion in alleged fraud losses. Roughly $4.5 billion of that was connected to telemedicine, the Department of Justice said.